Transcript
Gianluca Bini: All right. So whose topic is tonight, Ryan?
Ryan Bailey: Mm-hmm.
Gianluca Bini: Nice. What you got?
Ryan Bailey: Well, so I'll be honest, the inspiration did not come to me the last, like, I don't know, year or how long it's been since I've had to choose the topic. So I solicited some advice from friends. And given that, I thought little behind the scenes for the fucking viewers at home, were supposed to record yesterday, but some extenuating circumstances arose and we did not.
Ryan Bailey: But yesterday I was busy with a bunch of projects, so I did not have a chance to come up with all the normal litany of crap that I do in regards to these topics. So my friend, Gabby Escalante, also an anesthesiologist, gave me a great topic to discuss that I felt immediately stuck with me and the amount of energy it took me to come up with the ideas.
Ryan Bailey: you know, was low because they automatically just popped in my head versus some other ideas I was given that would definitely need to do more research on.
Gianluca Bini: OK.
Ryan Bailey: So, all right, are you ready?
Annatasha: All right. Yeah.
Gianluca Bini: So what you got?
Ryan Bailey: I want to talk about oral analgesic options specifically for dogs and cats. And we don't have to limit it to orals, but I want to focus on kind of the outpatient analgesic options that we talk about Maybe what we're recommending, what works, what doesn't work. Maybe we'll talk about some like old favorites that are new again all of the sudden.
Ryan Bailey: we'll talk about some hot topics that people fucking hate. I just felt like it's a good... don't really... This is an area where we're asked a lot of questions. And because of some of the workflow issues that we experience in our jobs, you know, we don't... We are kind of advisors, but not always primary decision makers on that. So, yeah, that's my long-winded windup.
Ryan Bailey: So what do you
Gianluca Bini: Well, and Zahid.
Ryan Bailey: got? Great.
Gianluca Bini: I got an easy one. Yeah.
Annatasha: First, I want to say, hate this question.
Ryan Bailey: I know. As soon as she gave it to me, was like, fuck. Like, it's such thing.
Annatasha: It's the right question to ask because we need to address things where we struggle and where we hate because that's really where you need bolster knowledge. And the reason, just so everyone knows I hate this question, is because...
Annatasha: It's just very challenging because there aren't a lot of options and not all the options are as efficacious as I think we want them to be.
Gianluca Bini: Thank you.
Annatasha: So it's nice to discuss it, and I think hopefully it will be helpful to the four people listening. But yeah, it's one of those things that kind of like, it's almost a little bit like to like oral sedation at home for like fractious patients. Like kind of makes you want put your head down and give up a little just because...
Gianluca Bini: Yeah.
Annatasha: And like Beanie says, like NSAIDs, but I mean, I find even still like NSAIDs upregulate people so unreasonably sometimes and they will just strike it off the list at like the tiniest little like ridiculous reason.
Annatasha: And it's such an important part of the spectrum of care. So... Yeah, good question. Good and bad question at the same time. Good needs to be discussed. Bad, it's a challenging thing to discuss. Yeah.
Annatasha: Beanie, you were saying NSAIDs before I casually interrupted as usual.
Gianluca Bini: All right, let's cut to the chase. Let's cut to the chase, right? What options do we have, right? So, NZ is probably one of the mainstay, right?
Gianluca Bini: I think, as you say, yes, we do have a lot of, you know, there is a lot of times, like, reasons not to give NZ. Sometimes it's probably... We may be too cautious, right?
Gianluca Bini: Like sometimes. So, yeah. I mean, so in which instances do you think NSAID is a no-no, right?
Gianluca Bini: Usually kidney, liver disease, right? Usually those are the two main reasons.
Annatasha: mean, honestly, Beanie, I'm not, I don't, I feel like everyone tars those cases a lot with the same brush. And I feel like there's, particularly for us, there's more nuance to that. Do it, you know, it's not just liver, because I think we need to talk a little bit about what that implies.
Gianluca Bini: Where? Okay.
Annatasha: Like, is it, is there sense that there's been some sort of liver irritation or is it liver dysfunction? And if so, on like, when, when is the scale appropriate? And it's the same thing with like, you know,
Annatasha: GI signs and and and you know if I have like a 19 year old cat who has like chronic renal insufficiency but is like an agonizing pain for a variety of different reasons am I going to withhold a medicamp no right because it's a question of quality of life over like worrying about adverse effects so I hate when people talk about NSAIDs in that way like I don't give it if it's liver kidney or GI and then we make
Gianluca Bini: so
Annatasha: ridiculous comments about things like platelet aggregation and really does, this is a specific area where I think we need to do much better because the discussion really does need to titrate itself down to being more specific. And that's, it's very similar, for example, like dexmed and cardiac disease, like, you know, like don't give dexmed you have cardiac disease. And it's like, oh, shut up.
Annatasha: And that's exactly the same thing that I feel about the NSAIDs too. Like you have to think critically through what is appropriate and what's in the best interest of the patient more so than I find, for example, like so many people are like, don't want do that because I don't want get in trouble. And I'm like, your job is to look after the patient, not after your own ass. So do a better job. So.
Gianluca Bini: I mean, both technically, right? Technically it's both. But so, yeah, no, I agree with you. And I tend to think, so I'm way more...
Gianluca Bini: I rely a lot on sometimes on what actually happened during anesthesia. If I have a patient that's been hypodensive for a while, tend to delay maybe the handset the night rather than giving it immediately post-op.
Gianluca Bini: I know that some clinics, they tend to give it pre-op, which I think is kind of a dangerous game to play.
Annatasha: I mean, this is a whole other podcast.
Ryan Bailey: Oh.
Annatasha: Like when should you give your NSAID? And I agree with you, Beanie. Like I generally, I don't give it before anesthesia if I think that there's a reasonable potential for to be a complication and I have been burned.
Annatasha: so many times for acute bleeds that were unexpected or for like ridiculous cases where you totally healthy patient that has like refractory hypotension for the whole anesthesia and you're like why is this happening know and you're just like so unless you're like kind of what I would call like out of the woods like for example you're past the point where hemorrhage is a huge risk you know or you know we're at closure or things like that okay fine go ahead but I feel like every 10 years we also it's like give the NSAID at the start, give the NSAID at the end, give the NSAID at the start, give the NSAID at the end.
Gianluca Bini: this
Annatasha: But like I said, I've been, I've definitely had my ass handed to me by things like severing of the popliteal artery during a TPLO. And now we have an NSAID on board and the criticalist is looking at you like, you know, you've recently had a lobotomy and you're like, well, I mean, that's not supposed to happen, you know,
Gianluca Bini: you know i think i think you know in terms of moa pre-op makes sense right but the the risk is so high that like i think that i rather it safe and just give it post-op or, know, a closure you know, when you're about to be done. You know, I think the intra-hop, we can manage pain much better with many other things that you don't necessarily need the hands-aids, right?
Annatasha: Okay.
Gianluca Bini: Post-op, you're way more limited. So, you know. But besides that,
Annatasha: Bailey, when do you give your NSAID? When do you give your NSAID?
Gianluca Bini: me?
Annatasha: Bailey.
Gianluca Bini: Oh.
Annatasha: Beanie and I already agreed, so we're just going to wait for you to say something Doppler.
Ryan Bailey: are you my pet are you my patient?
Annatasha: don't know.
Ryan Bailey: Because it differs, to be honest. It's because I don't have the evidence to support my wild ass theory. But, so my own personal cats who had dentals or whatever, they got NSAIDs the night before.
Ryan Bailey: They got it with like their Sirenia and their sedatives and they got their Anseor the night before.
Annatasha: Okay.
Ryan Bailey: And one of them had, So I think the one actually didn't get it the night before. I like scoured my house to find dose of Onsior, but I did not, or Robenococcin, whatever.
Ryan Bailey: I did not have an available dose for him. So he did not get.
Annatasha: Why did you serve like random like NSA just scattered through your house? You're just like bills, bills, on seor.
Ryan Bailey: Well,
Gianluca Bini: This
Annatasha: Like...
Ryan Bailey: I mean, just, you know, I make sure I have medications for my pets. So if they have to go to the clinic, I have some sedatives. So they're not assholes because one of them is a real, and I thought maybe I happened to have a dose from her dental procedure where, you know, she had some NSAIDs for post-op pain. and then I think actually when he, I will actually say when he went to the clinic, one of my requests was, well, before his anesthesia, was like, if you have oral on zero, can you give him a dose before we get started?
Ryan Bailey: and so that comes from like a, what John Luca said, the mechanism of action, we know going to be working like before the procedure starts. B, there was a older paper that showed patients who are on oral NSAIDs had like much lower pain scores no matter what pain medication plan they were administered during a TPLO procedure.
Gianluca Bini: Hmm.
Ryan Bailey: And so one of the journal club discussions we had on that paper was whether the oral encese has actually like helped with the pain they were experiencing. And so it didn't matter what pain options you chose, like HLK or epidural or whatever.
Ryan Bailey: And then there's, this is like where we're starting to really get out there is there's been couple, I'm just going to say controversial papers and discussions within and at our larger lecture series conferences, in which there has been question about the use of parenteral injectable NSAIDs and the rates of acute kidney injury that are reported.
Ryan Bailey: there's some speculation out there about, are we seeing the same rates with oral medications versus the parenteral medications.
Gianluca Bini: Gotcha.
Ryan Bailey: So all those reasons...
Annatasha: Well, what was the conclusion of that conversation? Because I'm curious to know.
Ryan Bailey: What's that?
Annatasha: What was the conclusion of that conversation?
Ryan Bailey: There is no conclusion. There is no conclusion at this time. The conclusion is more research needs to be done.
Gianluca Bini: Yeah, so that's useless.
Annatasha: Okay.
Ryan Bailey: What's that?
Gianluca Bini: So that's useless.
Annatasha: What the conversation? Okay.
Gianluca Bini: Yes, that's probably useless.
Ryan Bailey: I mean, you have to start somewhere once again.
Gianluca Bini: right, sure.
Ryan Bailey: So in my patient population, if they're on NSAIDs, great. If they give them orally, I'm not going to sweat it. If they have not gotten them orally and I need to decide, I'm going to recommend of an abundance of precaution based as far as I'm aware, actual evidence to support this claim that we all practice. I will administer them after anesthesia, assuming it all went well and we did not have experienced a hypotensive crisis.
Gianluca Bini: Yeah, I think that most of it comes from, you know, the increased potential risk of acute kidney injury. If you have the combination of hypotension, prolonged hypotension and, you know, NSA administration.
Gianluca Bini: Now,
Ryan Bailey: But is there evidence? Show me the evidence. I know the mechanism is there and I know the theory is there. I believe all of that, but show it
Gianluca Bini: No, no, I understand that. But like how many people in that math are actually looking for acute kidney injury, right? In humans, we do not send the people home till they pee after anesthesia, right?
Gianluca Bini: Like they wanna make sure you're not in that teneuric phase of AKI, which is the very first phase of AKI, right?
Ryan Bailey: What?
Gianluca Bini: In vet med, we ship the dog home or the cat home two hours afterwards, whether they peed or not, the owner is not instructed to even look for pee or for urination or not, right? Like half of the time, if you read the discharges, like nobody, I've,
Gianluca Bini: I can comfortably say that I've never seen anybody right on a fucking discharge monitor for urination. All right? Have you?
Gianluca Bini: No.
Ryan Bailey: I'm in agreement. I think there is...
Gianluca Bini: No. No,
Ryan Bailey: You're preaching the choir.
Annatasha: Let's just answer for each other. Have you seen it? No. Okay.
Gianluca Bini: I'm sorry. Anyway, so also, by the way,
Annatasha: This also, by the way, has nothing to do with oral medication. So we are doing a tip top job here.
Gianluca Bini: Oh yeah, we're totally diverging in a fucking rabbit hole as usual.
Ryan Bailey: Yeah.
Gianluca Bini: But basically, But that's the problem, right? So these studies are almost impossible to make in veterinary medicine. A, we're shifting a follow-up, right?
Gianluca Bini: Like, you know, somebody comes in, know, specialist sender, they do anesthetize that pet, they send it home.
Gianluca Bini: If six months later a year later, that pet has CKD, God knows,
Ryan Bailey: Right.
Gianluca Bini: right?
Ryan Bailey: Absolutely.
Gianluca Bini: Nobody follows up a year later or six months later. God knows. Also, we get blood work way less often. You know, our patients, right?
Gianluca Bini: Like, you know, maybe they came in, they had surgery, they go back home, they go to a regular vet, maybe like
Annatasha: Thank you.
Gianluca Bini: couple of months later, they do not get blood work till one or two years later down the road, right? Like, so the frequency that our pets get checked at, it's way lower than humans are.
Gianluca Bini: And so all of this contributes to the fact that these studies are almost impossible to make.
Ryan Bailey: Yeah.
Gianluca Bini: And that's why in 20 or 30 years or more of literature, there isn't one, because
Ryan Bailey: Yeah.
Annatasha: Well, I think we need to be careful because what I don't want to have happen is everyone starts checking blood work and then blaming us.
Annatasha: I don't need to hear about CKD six months down the road. And that also get tacked onto anesthesia's problem list. So, Of course.
Gianluca Bini: Sometimes it is. Like, why do you think all these cats out there have chronic kidney disease?
Ryan Bailey: Thank you. That's, I was like, and here's, here's, I'm going to jump in with my other crazy theory. reason cats all have CKD is because they're also fucking hypotensive under anesthesia and no one manages it correctly.
Annatasha: Yeah.
Gianluca Bini: Yeah, 100%.
Ryan Bailey: And they're all developing AKI multiple times at these stupid fucking dentals. And that's why you see all this CKD in cats.
Gianluca Bini: Well, wait.
Annatasha: You guys just did exactly what I told us not to do.
Gianluca Bini: Wait.
Annatasha: Not that you're wrong, but I was like, from a political standpoint, we really just shot ourselves in the foot, guys.
Gianluca Bini: So
Gianluca Bini: I think that more than the dendles, which I agree that sometimes it's...
Ryan Bailey: It's just the most common repeated anesthesia event for these patients.
Gianluca Bini: Gotcha. I think that most of the damage is made as pain neuter because those...
Ryan Bailey: Yeah, I think there's consistent damage though through time, but I do, do absolutely agree with you.
Gianluca Bini: How many...
Ryan Bailey: I think there's a major hit there. And then think there is additional subsequent hits in additional procedures because cats are just so, they're so frustrating.
Gianluca Bini: Sure. And let's make it clear if some pet owner is listening, this isn't a dendl where we're talking about people that do not monitor their patients appropriately or they do monitor them but not take the appropriate interventions.
Ryan Bailey: Yes. Right.
Ryan Bailey: Yeah, absolutely.
Ryan Bailey: Yes.
Annatasha: Yeah, to be clear, we're not talking about us three.
Annatasha: Well, I live in hope that that is a true statement, but I definitely want to be like, it's not the three of us. Yeah.
Gianluca Bini: Okay. But, you know, I think that the major hit do really comes at, you know, spay and neuter with the excuse of being a relatively short procedure in the 20 to 30 minute range.
Ryan Bailey: In a healthy patient who has reserves.
Gianluca Bini: In a healthy patient, there is clinics out there that do not monitor blood pressure. And there is clinic that if they do monitor blood pressure, don't have a way to fix it.
Ryan Bailey: Yeah.
Gianluca Bini: Right.
Annatasha: Listen, there clinics out there who send pets home with comminuted fractures and no oral medication, so.
Gianluca Bini: And so that's it.
Ryan Bailey: And they may or may not be intubated because the evidence suggests that intubating a cat can lead to like higher likelihood of complication in a very old paper that still gets brought up.
Gianluca Bini: I mean, that's...
Annatasha: paper. One paper.
Annatasha: 100%.
Ryan Bailey: That still gets dragged out from time to time.
Annatasha: I have to, yeah. Mm-hmm.
Gianluca Bini: Yeah. So long story short, there's people out there that do bunch of sketchy shit.
Gianluca Bini: And that's why a lot of the cats do suffer kidney damage.
Ryan Bailey: Like, like the people who fucking give their own cats at home their, you know, right around NSAIDs.
Gianluca Bini: And that's Ryan Bailey for you guys. anyway,
Ryan Bailey: So, Martel, when do you give your cat, your pets, when do you give your patients their NSAIDs and how do you manage that?
Ryan Bailey: Yeah. Oh,
Annatasha: I'm the same as Beanie. I like to clear the air, but you should also know that my cat has been on daily meloxicam for over three years to manage chronic DDG and OA.
Ryan Bailey: yeah.
Annatasha: could not have more perfect renal values probably up until this afternoon, but that's for a whole other reason.
Ryan Bailey: Exactly.
Annatasha: So, yeah, BW got diagnosed with carcinomatosis this afternoon.
Gianluca Bini: What
Gianluca Bini: the fuck?
Annatasha: So, yeah, it's okay.
Gianluca Bini: I'm sorry.
Ryan Bailey: that are happening.
Gianluca Bini: Is this brownie?
Annatasha: The one who swims, My swimmer.
Gianluca Bini: So brownie.
Annatasha: No, Brownie's fine. Brownie's just a diabetic and an asshole, but BW is the one who goes swimming and is on all the videos.
Gianluca Bini: Oh, brownie.
Annatasha: Yeah.
Gianluca Bini: Oh.
Annatasha: Yeah.
Gianluca Bini: Poor guy.
Annatasha: But anyway, so yeah, that cat had been on meloxicam for years on a daily dose just to manage like chronic degenerative joint disease. So, you know, I am not, and the other thing too is, here's a quick question about NSAIDs.
Annatasha: do you guys always perform blood work, for example, before you recommend or prescribe an NSAID?
Gianluca Bini: Well, usually because it's post-
Annatasha: Like, would you consider that standard of care or a best practice? Because I feel like it's a little old school in my opinion, but I don't know, like, where do you guys land?
Gianluca Bini: I don't think outpatients you need to, but like, you know, in terms of like, you know, probably our field of work, I think usually our patients do come in for a procedure and then they get prescribed an NSAID afterwards.
Gianluca Bini: So they do come in with blood work, not because of the NSAID, but because of the procedure. So like, you know, that's, that's,
Ryan Bailey: Mm-hmm.
Gianluca Bini: That's my answer there. I don't run a pain clinic, so I know if I would have her lean that way. don't know what you think, Ryan.
Ryan Bailey: Yeah, so I think in our surgical, in our patients undergoing anesthesia, I think it's a bit of a different story for sure.
Annatasha: Thank you.
Ryan Bailey: So think, yes, recommending blood work in those situations. I think from my opinion as a veterinarian, knowing the incidence of acute kidney injury in our pets and our ability to treat those patients with anxiety,
Ryan Bailey: what ends up becoming chronic kidney disease being somewhat limited, species dependent for sure. I think it behooves us to at least inform owners of the risks of this, the potential for risks of this drug.
Ryan Bailey: and inform them of the options to mitigate those risks and whether they want to go through with that is up to them as long as they have the informed consent. But I think it's in our best interest to provide what we think is best for the patient, taking into account all of those risks. So let's here's a good example, you have an old crunchy cat who has a little laceration and maybe want to prescribe an NSAID, but the owners don't want to do blood work.
Ryan Bailey: I think that when you have to weigh a little more heavily than young healthy cat who has a laceration and you want to prescribe an NSAID, I think you can be a little bit more liberal if the owners don't want to go forward with blood work, just kind of assuming little bit of risk in those two different populations. Now in a dog, I think general rule of thumb that I would follow is like, if they don't want to do it, it's probably okay go ahead with it.
Ryan Bailey: At the same time though, dogs who develop CKD don't have the same levels of, like, I don't think they have the same like survival that cats do because cats get CKD and then they live for fucking ever.
Annatasha: Thank
Ryan Bailey: But dogs that develop like kidney injury and CKD, like, time's ticking, you know? And so like, if you do contribute to that, like that is, that is not an insignificant thing in dogs. So I think that is, that's something to weigh for sure. So I don't, it's not to me cut and dry, but I do think we should be a little bit more liberal with our NSAID use personally.
Ryan Bailey: That's long-winded.
Gianluca Bini: so
Ryan Bailey: Oh yeah.
Annatasha: You know, and think that constantly running blood work, like it can be cost prohibitive. And also, you know, I'm not sure what the value is. My next question though, is like, how many times have you guys incurred in your clinical experience, like an actual case of AKI that you really felt was directly related to like that recent anesthesia in which you were involved?
Ryan Bailey: Okay.
Gianluca Bini: I, to be honest...
Ryan Bailey: I would have predicted it. before the patient even came out of the case. You know what I'm saying? It's like this hypotension that's intractable. The patient came in in septic shock that was not adequately resuscitated prior to anesthesia because of time slash, you know, the disease process.
Ryan Bailey: You know, it's like, I'm doing the best I can, but I'm sure I'm not going to prevent AKI in those cases.
Gianluca Bini: Yeah.
Gianluca Bini: Yeah. Yeah.
Annatasha: Okay. Yeah.
Ryan Bailey: So like,
Annatasha: I've only had one case however many years. And it was exactly that type scenario. Like, you know, you had to go, the patient wasn't optimized, you know, it wasn't stable, but it couldn't be stabilized without surgery.
Annatasha: And it went in already on sort of the cusp of AKI. And I was like, and it was, you know, a crappy anesthesia. And I was just grateful to get it off the table, but the criticalists and I knew like tomorrow, like we're gonna be managing AKI, but that's once out of over 10,000 cases. So my question is, are we too worried about AKI?
Gianluca Bini: But
Ryan Bailey: But at the same time, there are probably... a large amount patients are developing acute kidney injury that goes undetected because we're not looking for it. And it resolves because the kidney does have some residual, like some robustness that it can, have some, some cell death and not be, you know, a disaster.
Annatasha: What you think?
Gianluca Bini: I don't think we're too worried about it. I think we're, again, we're not looking for it. think that, you know, the extent of your case was probably worse than, you know, the, we're talking about AKI, but like in general, like it's not the whole kidney that gets damaged, right?
Annatasha: Okay.
Gianluca Bini: Like, you know, there is a portion of it that gets damaged.
Ryan Bailey: Yeah.
Gianluca Bini: Like it doesn't happen all, it's not a whole of nothing kind of thing, right? So I think that the extent of the AKI also matters, right? And probably the situation where you have a septic patient or something that is a plegic or whatnot, of course, the damage that will be done there is way different than... And again, I'm not condoning who doesn't measure blood pressure and does not fix blood pressure, but then the...
Gianluca Bini: you know, 15 or 20 minutes in an unholy cell decat that goes under anesthesia for a spay in the clinic is doing a shitty job at it. Okay. So like, that's not, it's probably a very different situation. Right.
Gianluca Bini: the extent of the AGI is going to be different too. one thing that I was, you know, going to mention is like,
Gianluca Bini: So we've been talking about NSAIDs the whole time. I think that some people also forget the steroids are a good option for analgesia, right?
Gianluca Bini: Like, know, there is patients that cannot get an NSAID, but you could use steroids, right?
Ryan Bailey: So, You are like, you're on it today. just want to say that. was already, first of all, I was like, we gotta move on. We gotta like have some final parts on NSAIDs here and we gotta get to the next topic.
Ryan Bailey: Cause we're gonna spend an hour on NSAIDs. And had I known we could have spent an hour on NSAIDs, I would have been a lot lazier. me be honest. But like, why?
Annatasha: Okay.
Ryan Bailey: Are we not using steroids? Like, why? Why? I could, like, used to offer them all the time in my previous shot and be like, oh, you don't think it can have an NSAID? Well, how do you feel about a dose of steroids? Or how do you feel about a short course of steroids? And I might as well have been like, let me get out the ax and murder the patient in front of you. Would that be okay? Would you be okay with me doing that? Like, I don't, I could not for the life of me figure out the aversion to using steroids, like a short course of a steroid, like a week or whatever.
Gianluca Bini: I think there is a lot of aversion on steroids, right? Like, you know, and people, I think that people sometimes, A, they mishandle steroids, like dosing, right?
Ryan Bailey: Right.
Gianluca Bini: They go with way higher doses than, they don't understand that the, you know, the analgesic dose is lower than ant-inflammatory dose, which is lower than the, you know, know, um,
Ryan Bailey: Yeah.
Annatasha: immunosuppressive,
Gianluca Bini: immunosuppressant dose, right? So like there is different dosing levels and there is different effects at different doses. So, and there is different side effects at different doses.
Ryan Bailey: Absolutely.
Gianluca Bini: So the side effects that you get at the immunosuppressant dose, it's way worse than what you can get at the anti-inflammatory and or the analgesic dose. So every time that people think about steroids, they think about, okay, delayed wound healing, you know, what sort of side effects?
Annatasha: PUPD,
Gianluca Bini: Yeah, PUPD or that stuff.
Annatasha: question for you guys about steroids then like i i mean steroids are monster analogies like in human anesthesia right like it is
Ryan Bailey: Steroids and insects, that's like a common thing for humans to go home on.
Annatasha: there's they're much more reticent about opioids than we are but question like you feel in terms of like the anti-inflammatory capacity of an NSAID versus a steroid which one do you think is more efficacious
Ryan Bailey: For good reason.
Gianluca Bini: or steroids.
Annatasha: Okay. Based on what?
Ryan Bailey: Yeah.
Annatasha: Dear gentlemen, based on what?
Ryan Bailey: Yeah, that's great question.
Gianluca Bini: Yeah.
Ryan Bailey: mean, at least the mechanism of action, for sure.
Gianluca Bini: Mechanism.
Ryan Bailey: It works higher up in the chain.
Gianluca Bini: Yeah. And I think it works on way more being an endogenous, you know, usually you do release your own steroids, right? Like, so I think that it had some way more.
Gianluca Bini: Correct.
Annatasha: So based on basically like clinical reasoning, but we really don't actually know the answer, do we?
Ryan Bailey: yeah would say that's a fair
Annatasha: I mean, I will say too, in the last couple of years, right? Like for example, if you're doing something where you have like concerns about airway inflammation. had a lot of long conversations about should we give the steroid or should we give the NSAID and which one is really more efficacious in terms of anti-inflammatory. There's some newer vets, newer specialists coming out who are really driving the NSAID conversation versus the very rigid old school mentality that the NSAID is really the more potent and anti-inflammatory. And Personally, I don't have the answer. And I've, I've done both. And sometimes I've done both together because it's been a real fucking shit day. But yeah, I, I don't think there is an answer unless I have completely missed the plot.
Ryan Bailey: The only caveat I want to put on what you just said, Bartel, though, is like, is that conversation coming from the like delayed wound healing, increased dehiscence kind of conversation, aversion to, like it's an aversion to steroids and choosing NSAIDs in that situation versus like, you know what I'm saying?
Annatasha: Which is possible. Which is possible.
Annatasha: I don't have an answer to that. And it's possible that maybe that was the background, that process. It's not been like the forefront of the dialogues that I've sometimes had.
Ryan Bailey: Yeah.
Annatasha: Like a lot of the surgeons I worked with in Singapore, like we always, we sort of sat there and it was like, well, which one is better?
Ryan Bailey: Oh, for sure.
Gianluca Bini: Yeah.
Annatasha: So which one should we give, right? And sometimes if we had a like low indice of like, you know, indices of risk, Maybe we erred on the side of the NSAID. If we were really confident that the Frenchie was completely going to have to end up like having a trach, we would err on the side of the steroid.
Annatasha: I've made, I've had that before where I've given the NSAID for something totally unrelated, like had a polytrauma once who then its entire neck swelled at extubation. And then the criticalist was furious because they couldn't give the steroid.
Annatasha: And I was just like, well, technically can give them both together, know, blah, blah, blah. But yeah, there, I don't think there is an answer and nobody really asks this question.
Gianluca Bini: Yeah, that's fair.
Ryan Bailey: How can you tell, though? I mean, like, just a silly...
Annatasha: Well, that's another thing. How do you quantify the degree of anti-inflammation? You can either stick a tube in its trachea or you can't.
Ryan Bailey: Right, for sure, for sure. Yeah, like, I... I never got a lot of buy-in on using steroids, and I never, like in the patients that I saw as primary, I never really had occasion to recommend switching to a steroid for those guys, just because most of them were osteosarcoma cases, and I felt an NSAID was the better choice for those guys, but I'm sure I was seeing a different kind of
Ryan Bailey: pain patient for a different kind of cancer, I feel like maybe I would have pushed for steroid in those situations.
Annatasha: Which is nice because you can give orally, right?
Ryan Bailey: Mm
Annatasha: Like you can send them home and steroids are cheap and cheerful. Now I do get that. I've had patients before that they have gone home on oral steroids and like, it's interesting because like their side effects are so marked, you know, like they just go from zero to just like, like just uncontrollable, like urination all around the house.
Ryan Bailey: hmm.
Annatasha: And the owners are like, look, like if this is the answer so that my dog has better longevity for the next month, then I'm just going to stop altogether. And so I don't know, I find, you know, we're sort of relaxed about the side effects associated with steroids.
Annatasha: And it's probably because they don't incur like something is potentially life threatening as like a duodenal perforation, theoretically.
Ryan Bailey: Yeah.
Annatasha: But, you know, I think from the point of view of the client and the client pet relationship, and how that's actually impacting the longevity in terms of the pet, I think we do need to maybe have a little bit more careful consideration about the steroid.
Gianluca Bini: Thank
Ryan Bailey: Yeah, and there also is an owner aversion to steroids at times because the side effects in humans on steroids can actually be quite severe. And so some humans are quite averse steroids.
Annatasha: Oh, yeah. They get rage. Yeah, they get the steroid rage. They can get incredibly, like, edematous. Like, it can be very challenging. had lot of friends who had to take steroids associated like, chemotherapeutics when they went through cancer treatment.
Annatasha: And, like, they reported that sometimes, like, the steroids were the harder one to endure, know, because, like, they couldn't sleep. Like, they, you know, like, it was just, like, they were just manic all the time from the steroids.
Annatasha: So, but, yeah.
Ryan Bailey: And we want that for their community.
Annatasha: So, oral meds. So, check on steroids. Check on NSAIDs. What else?
Gianluca Bini: How about Tramadol?
Ryan Bailey: Okay. How about...
Annatasha: How about Tramadol?
Ryan Bailey: What do
Annatasha: How about Tramadol?
Gianluca Bini: Right? I mean, I think there's people...
Ryan Bailey: you want to call crack at all?
Annatasha: Tramadol is probably, it's in the shithouse, right?
Ryan Bailey: Or...
Annatasha: And I feel like we've totally like tossed it out.
Ryan Bailey: For what species?
Ryan Bailey: I know you're fly athlete.
Annatasha: But I still think that it has its place. Do you guys agree?
Ryan Bailey: In the patient's eyes.
Annatasha: I mean, my opinion, Go for it, Bailey, go for it, sorry.
Ryan Bailey: No, no.
Gianluca Bini: for it.
Ryan Bailey: I like how you asked the question and then you started to answer your own question before you gave us. Usually I just notice kind of a give and a take with you. You're like, I'm going to give my long-winded question about this and then let you go into it.
Ryan Bailey: And you just had so much to say you couldn't hold back. So knock out.
Annatasha: I mean, to be fair, earlier, John Luca did ask you a question and then answer on your behalf. At least in this case, I just answered my own.
Gianluca Bini: Oh my goodness, you guys.
Annatasha: I don't know, Tramadol, what do you think? Like, I mean, cats, for example, how you feel about Tramadol and cats? Because they're a lot more interesting, in my opinion, than dogs.
Ryan Bailey: thumbs up. Double thumbs up in fact. I mean, the evidence is there that it works if you get into them.
Annatasha: Can you get the cats in the cat?
Annatasha: That's the thing.
Ryan Bailey: But like, yeah.
Annatasha: Can you get it in the cat? Because Tramadol tastes butt.
Ryan Bailey: I mean, you can use like a pill pocket or you can get it compounded or there's the little tiny tabs or whatever. Although, although like I have some really strong feelings about cats and like,
Ryan Bailey: I mean, management options. I know, like, a shock. Bailey has weird opinions on cats. But, like, for cats, like, oral medication, fucking, why are you orally medicating your cat? There's so few, there's so many more options for cats of drugs you can give them that have prolonged action that don't need to be administered, you know, by mouth.
Annatasha: Such as?
Gianluca Bini: You're talking about Fendonit patches?
Annatasha: How
Ryan Bailey: No, no.
Annatasha: about a lidocaine pack?
Ryan Bailey: I mean, you got Zorbium, you got sustained release buprenorphine.
Gianluca Bini: No, no, no, no, no. Let's rewind. So let's talk about Fendonit patches, Ryan.
Annatasha: Technically not oral, so not really on the purview of tonight's conversation.
Ryan Bailey: it was, I expanded it.
Ryan Bailey: I said it is outpatient analgesic options.
Annatasha: Oh, okay, okay. Sorry, I wasn't listening as usual because I don't care.
Ryan Bailey: Sucking.
Gianluca Bini: So what's your thought on Fendonet patch? Because that's a long-term analgesic option, really.
Ryan Bailey: For sure. For sure. I mean, from clinical experience from my understanding of the literature, they are trash they should generally be recommended patients to them is my opinion the absorption is erratic if at all at least based on you know the pharmacokinetic studies which i mean we're relying on the drug to get into the body so it's not getting into the body what is the fucking point and then
Annatasha: I love listening to Bailey always try to be diplomatic and then just unraveling. Like, that's one of my favorite things where he'll be like, look, I just, you know, if there's no other option and like, you know, it could be, fuck this.
Gianluca Bini: Yeah.
Ryan Bailey: right
Ryan Bailey: I mean, are probably patients that we need to think about it for.
Annatasha: Yeah.
Ryan Bailey: And like, it's probably the last line and like, it's an unpredictable, it's like, like I can tell you, I had a dog growing up. He was on tramadol. The tramadol seemed to help it. This was before I knew anything about these things.
Ryan Bailey: And like, there are probably some patients who have an altered pathway and they do have, they make the Odesmethyl tramadol and it works for them. It's just unpredictable in dogs. Cats, everything else, they're fine.
Ryan Bailey: Give them, give them all the tramadol you want. It doesn't matter. but the federal patch, like it just doesn't seem to absorb because their skin is just different than humans. And so we don't get plasma concentrations.
Ryan Bailey: And then the ones we do, they all get fucking manic as hell. And like you tell the owner to pull the fentanyl patch off and the dog is like right as rain and everything's fine. And like, is, was that beneficial for the dog to be like screaming at home and like bothering the owners and anorexic and this and that, like that's also probably not beneficial either.
Gianluca Bini: I mean, feel like, know, depends on the patient, right? There are some patients that do well on it, some patients do not.
Ryan Bailey: Sure. Yeah.
Gianluca Bini: Yeah, I mean,
Ryan Bailey: And what I say applies to like when I, you know, obviously I'm the one who's like, well, the paper says this and it's like, I'm choosing to look at it as like a population level. I'm not thinking 5%. I'm thinking 95%. I'm thinking what are the chances of the patient front of me responding well to this medication or poorly test medication? And I'm going to take the good odds and not the like 5% odds.
Gianluca Bini: Fair.
Ryan Bailey: I'm looking for a horse, not fucking unicorn.
Gianluca Bini: Fair.
Gianluca Bini: So right in the wave of topical stuff, right? Like, what about Zorpium?
Ryan Bailey: I use it a fair bit in previous job. I got burned quite a few times, absolutely, for sure. Like, some of those cats got manic because cats and opioids are not always good mix.
Gianluca Bini: Nice. Nice.
Ryan Bailey: And it sucked, for sure.
Ryan Bailey: I used to be pretty militant about, like, no buprenorphine for cats before a surgical case because...
Gianluca Bini: So yeah, that's
Ryan Bailey: what if we want to do this or that or whatever? Like what if money is a Pyramid Wagonist? And then I totally relaxed because the evidence for cats is continuing to mount about Pyramid Wagonist not being the hot shit we like to think they are.
Ryan Bailey: And so I tended to be like, oh, well, the cat's got buprenorphine, like log-acting buprenorphine on board, so it will be copacetic, essentially.
Ryan Bailey: But there were definitely some cats that got manic. But I also think for owners, it's just such a...
Ryan Bailey: It's just such a gift if they don't have to like orally pill this cat.
Annatasha: Thank you.
Ryan Bailey: Cause like, let me tell you as an owner of two cats, one of them, that cat is as dumb as a rock.
Gianluca Bini: Yeah.
Ryan Bailey: And you just put the fucking chew rule out. You, I, I gave them like a massive, like, like dog-sized trazodone for him and he just like slurped that thing down like was nobody's business. Carol's like, how is gonna eat this horse pill? And I was like, don't you worry. And he just fucking took it like a champ.
Ryan Bailey: The other cat, if have to orally medicate her, it's like, honestly, I'd probably have to consider like, I don't know.
Annatasha: Anesthesia in a stomach tube.
Ryan Bailey: Yeah, exactly. Exactly. Cause like, it's just, there's no, like getting oral medications into Lucy is like literally hell.
Annatasha: I think the other thing that I also find that a lot of people like in terms of compliance can be a limiting factor is the number of oral medications and also the frequency of the dosing, right?
Gianluca Bini: Yeah.
Ryan Bailey: Absolutely.
Annatasha: Like, God, I mean, same thing with me. Like, first of all, the chance of me oral medicating Brownie is the chance of me launching into space and discovering a new planet. And then if I were to go home and have like four different medications and one's at 12 hours and one's at eight hours and whatever, I would never see that cat again.
Annatasha: That cat, I would never see that cat again.
Annatasha: And if I did, we would have full on scale warfare. And I'm not sure in terms of quality of life for either of us, I would be like, I need another option. Now I can... bring home needles and do my own injections type drama-rama, but most people cannot. So, you know, when they go home with one of those, you know, like those brown bags full of like 95 medications, I'm like, what do you think the odds are that they're going to actually get that done and B, finish the course of treatment? Because I just think it's so impractical.
Ryan Bailey: I think about that. I even see all these cats go home and all these like pill vials and I'm like, who are you fucking kidding? That cat got one pill?
Annatasha: And we all have like these tricks. We're like, well, I'm going to put it in butter and I'm going to mix it in tuna sauce. And I'm like, cats, you can get away with it one time.
Annatasha: And then they'll be like, oh, I'm not falling for this shit again.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: Right? Like there's no way.
Ryan Bailey: They tried to fuck you. These fuckers tried to fucking poison me.
Gianluca Bini: So, okay. But on the Zorbium side, right, I think that there has been bunch of reports of cats that got overly sedated on it, right?
Ryan Bailey: Oh, yeah, I think that's true, too. I mean, I also had a rule of thumb.
Gianluca Bini: Right?
Ryan Bailey: Only the big Zorbium, no matter the size of the cat, and, like, because every cat to me is five pounds, and so it was all.
Gianluca Bini: Wait, wait, wait, wait. You will always give the...
Annatasha: Five pounds or five kilos.
Ryan Bailey: Like, five kilos, you're right, sorry. Like, because it's over six pounds was the dosing, so, like, the big cats didn't get any more.
Gianluca Bini: There is two sizes, right?
Annatasha: I would say, oh, this is one guy.
Gianluca Bini: Wait, let me figure this out.
Ryan Bailey: You know what I mean?
Gianluca Bini: So there's two dosing of sorbium, right?
Ryan Bailey: Yes.
Gianluca Bini: The low dose and the high
Ryan Bailey: Under six pounds, which is 0.4 mils or one mil, which is 20 milligrams, which I also don't understand, but I, that's like a further issue.
Gianluca Bini: Okay.
Ryan Bailey: No,
Gianluca Bini: So you were giving small dose to everybody.
Ryan Bailey: no, I gave the big dose to all adult size cats.
Gianluca Bini: Jesus, right. Okay, so I have clinics saying the opposite, right? They gave the small dose to everybody because they don't wanna overly sedate them, right?
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: Well, is it better to overly sedate them or underly treat them too?
Ryan Bailey: Yeah.
Annatasha: Because this is one of my pet peeves about buprenorphine in general is that people give these bullshit sub analgesic doses clinically to cats who've had major therapeutic intervention.
Annatasha: And I'm like, what are we trying to achieve here other than make ourselves feel better about dumb decisions?
Ryan Bailey: Yeah. I mean, I... Whoa.
Annatasha: Do you give Zorbine any...
Gianluca Bini: Do I give Zorbium? No, usually, know, that's not something that we... I mean, unless the clinic asks for, you know, advice.
Annatasha: Me either. So I'm pretty sure we're going to get some Zorbium sponsorship for the podcast.
Gianluca Bini: Yeah.
Annatasha: Medelia.
Ryan Bailey: do know, do know a fair number of reports about that causing a degree of sedation that was not really appreciated by anesthesiologists.
Ryan Bailey: And so they tended to dose down and found it to be a better balance of like sustained analgesia wall. But that one also never made sense to me because it's a deep, it's just like a big old dose. It's not a special molecule. So like,
Ryan Bailey: We haven't even touched a bunch of them.
Annatasha: makes for a pretty interesting podcast. But yeah, opinions. It's
Ryan Bailey: What about Acetamethin? Because that's the new thing that's sweeping the nation. It's the new old thing. It's old, but it's new again, and everyone loves it.
Annatasha: only new in this continent. Everybody else has been on the paracetamol like train.
Ryan Bailey: I get a million questions about it and I'm like, I'm unprepared to answer that because it's an institutional specific thing and I wasn't an institution specific to it. So I can't answer that question for you, unfortunately.
Annatasha: Yeah, it's only new in North America, right?
Annatasha: Like the EU, the UK, Australia, New Zealand, parts of Asia, like they've been all on top of that situation.
Ryan Bailey: Oh yeah.
Gianluca Bini: Yeah, they were using it.
Annatasha: So...
Gianluca Bini: We had injectable, they call it paracetamol, we call it acetaminophen.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: But, I mean, we had injectable all the time in England. think it's newish to us. But I mean, I think it works.
Annatasha: Do you think it works as standalone though, Beanie, or more as an adjunct?
Ryan Bailey: When are you waiting for it?
Annatasha: Because certainly the literature is not super fan of the efficacy of paracetamol as first line or as a standalone.
Gianluca Bini: I think it's jammed, you know, with other things.
Gianluca Bini: It's true. Yeah.
Annatasha: I often use it in addition to something else. But I mean, as a person who suffers from migraines, Tylenol ain't getting the job done, let me tell you.
Gianluca Bini: Yeah.
Ryan Bailey: But what about those patients who maybe you don't want to use an NSAID? Would you feel more comfortable using acetaminophen, paracetamol in those patients?
Annatasha: yeah
Gianluca Bini: Yeah.
Ryan Bailey: Are you worried about the same kind of risk giving it? If you work in a place where you have the injectable formulation, because like in humans, you get injectable paracetamol, I think quite commonly before major surgical procedures, if I remember correctly.
Ryan Bailey: And so like, yeah.
Gianluca Bini: I'm not worried about AKI. The risk with Tylenol or acidaminophen, it's, it's, it's more on the liver side than on the, than on the kidney side.
Ryan Bailey: Yeah.
Gianluca Bini: So in patients with liver disease, yes, I am worried about Tylenol too. Right. But, again, it depends on what kind of level of liver disease we're talking about.
Ryan Bailey: Right, for sure.
Gianluca Bini: We're talking about dysfunction or we're talking about mild elevation of liver enzymes, like who gives a fuck.
Ryan Bailey: Yeah.
Gianluca Bini: Right. But,
Ryan Bailey: Yeah.
Gianluca Bini: But I think Tylenol definitely can be used more, quote unquote, freely or with less risk than NSAIDs in some cases.
Ryan Bailey: Yeah.
Ryan Bailey: As long as you're not a cat.
Gianluca Bini: Correct, not that.
Annatasha: I knew you were going to say that.
Ryan Bailey: I mean, we should just clarify for the people who don't have lemon-jones open front of them and don't remember everything about acetaminophen that is not for use in cats.
Gianluca Bini: No, that's fair.
Annatasha: It's the dog thing.
Gianluca Bini: That is fair. That is.
Ryan Bailey: Isn't that a methemoglobinemia drug for them?
Gianluca Bini: Yeah.
Annatasha: Well, there's a P45 cytochrome limitation that will, yeah, that then drives up your plasma concentration and that's what perpetuates the toxicity. Okay, that's fine.
Gianluca Bini: Correct.
Annatasha: That's fine. don't care. Yeah, we'll shut
Gianluca Bini: What about Amanda then?
Ryan Bailey: Did I use it? It was always in my arsenal. So let me tell you, I had a pain clinic. I saw maybe 10 patients. The majority of them were osteosarcts.
Gianluca Bini: Will go in your lifetime or a day?
Ryan Bailey: In like the time I was in the job, like that was the amount of patients. And it was almost all osteosarcoma patients who didn't want amputate, who had seen the surgeon, who then referred them to see me to talk about pain management. And the first step for me was unravel their like pain medication history and talk to them about like,
Ryan Bailey: what viewed as a entry level pain management plan to start this patient on so we could get like some good baseline information about what works and what doesn't work before we start throwing the kitchen sink and the owner has a thousand fucking pills to give the dog.
Ryan Bailey: Yeah. So I, it was always mentioned as like, think I chose a mantidine was often a second line drug for Most of it was like, well, let's get you on like a regular non-steroidal anti-inflammatory drug.
Annatasha: Yeah.
Ryan Bailey: And let's talk about how we're going to utilize opioids. And then brief discussion. So I will say did in those patients, given the type of disease process they had, I did recommend gabapentin, but also did add the caveat that like it can be hit or miss.
Ryan Bailey: And some patients absolutely love it. Some patients absolutely hate it, which I also learned when I was at the human pain clinic. Some people think gabapentin actually changed their life. And some people are like, this is the worst drug I've ever been on.
Ryan Bailey: And I never want to take another pill because I feel like I'm in a fog. So that's where I started personally.
Gianluca Bini: So, Amanda then, as an agent, probably okay, not first line. Okay.
Ryan Bailey: Yeah. And the evidence for amantadine that's stronger, I think, was amantadine combined with an NSAID for pain.
Gianluca Bini: How about oral?
Gianluca Bini: Got
Ryan Bailey: So that's...
Annatasha: I think you should get though, which is like something important too, like your first dose of amantadine is unlikely to really have any analgesic efficacy, right?
Ryan Bailey: Yeah, absolutely.
Ryan Bailey: Absolutely.
Annatasha: Also true of gabapentin, right?
Gianluca Bini: Cheers, Abuelo.
Ryan Bailey: Yes.
Annatasha: I think, you know, building to effective plasma concentration for your analgesic threshold is an important consideration. So you can't just jump the gun with imantadine. I happen to like imantadine very much as a chronicity, as an adjunct. And I really sort of push...
Annatasha: The dosing label limits as well, like, you know, it's supposed to be three five mg per kg per day once a day, but, you know, there's some more evidence coming out that if you do it twice a day, like Q12, and, like, you can go up on the dose, and, like, I will edge them up, particularly for in that specific instance where if you have, like, multifactorial complex neoplastic pain, and it's really, at this question, it's 100% palliative, then I really don't give two shits about that dosing, right?
Ryan Bailey: Right. Yeah. Right, right.
Annatasha: So... The safety margin for the NMDA receptor antagonist is enormous, which is why I feel comfortable in doing so, just so our listeners understand that.
Ryan Bailey: Yeah.
Gianluca Bini: So how about oral buprenorphine?
Annatasha: In which species?
Ryan Bailey: Well, I would be a miss if I didn't mention that the papers in which it was originally described were given oral transmucosal and then sampling the jugular vein.
Gianluca Bini: Pots and dogs.
Ryan Bailey: So they probably overestimated plasma concentrations to some extent.
Annatasha: That's a very interesting insight.
Gianluca Bini: Okay.
Annatasha: I like that.
Gianluca Bini: That's fair.
Ryan Bailey: Yeah, that was shout out, shout UC Davis.
Ryan Bailey: Shout out Bruno Pippin.
Ryan Bailey: It
Gianluca Bini: Nice.
Annatasha: I mean, that's the type of nitpicky bullshit that we're accustomed to with Dr. Bailey. But no, that actually, that's a good point too, especially if it does, if it is filtering down from Bruno is like the pharmacology.
Gianluca Bini: Yeah,
Ryan Bailey: is.
Annatasha: Yeah.
Ryan Bailey: I feel like might've repeated that experiment and looked at like arterial concentrations to like get a better, you know,
Gianluca Bini: that's fair.
Ryan Bailey: like to do it right. And I think they were overestimated marginally, but I think they were still potentially therapeutic. I mean, I'll tell you, it works in my cats. Both of them. Oh, Lucy, they love the buprenorphine.
Gianluca Bini: I
Ryan Bailey: They're fiends.
Gianluca Bini: think it works. I mean, I think it's good...
Annatasha: I like buber nerfing in cats specifically.
Ryan Bailey: Yeah, I agree.
Annatasha: think it's.
Gianluca Bini: How concerned are you, granted that, again, we usually are not the one prescribing this, but are we worried about diversion?
Ryan Bailey: Absolutely. I mean, we so like, I don't know what the what the laws are like, where you all practice, but I do know some colleagues who practice on the West Coast who do have to get fairly extensive opioid histories about their owners before they can prescribe them oral opioids.
Annatasha: Are we talking about buprenorphine specifically?
Gianluca Bini: Yeah,
Annatasha: Oh, okay. No, I mean, buprenorphine is sometimes used in human medicine as the weaning opioid for severe addicts, right? Like if you're coming off heroin or what have you, buprenorphine can be an alternative to methadone, right?
Annatasha: So, yeah.
Gianluca Bini: no, no, that's fair. But that's I'm like, you know, I think we're worried about diversion from a legal standpoint, but I think that from a practical standpoint, it's probably...
Annatasha: I'm not that worried.
Gianluca Bini: The same with, you know, when people ask about, you know, I'm worried about keeping a schedule two in my clinic.
Ryan Bailey: Yeah.
Gianluca Bini: First off, I always tell them that, you know, doing poor analgesia, you know, the diversion is not an excuse for shitty analgesia.
Ryan Bailey: For sure, for sure.
Gianluca Bini: And, you know, the answer to diversion is a fucking camera above the lockbox. But, you know, methadone, technically, you know, what diversion do you have? Like, what do they do with it? Do they get better?
Gianluca Bini: Like, you know what mean? Like, how, who's going to steal methadone? You know what mean? Like, so, I don't know. I think that we are worried about it from a legal standpoint. There is a chance, but like,
Gianluca Bini: I think that probably we're a little bit overly worried, right?
Ryan Bailey: I mean, I think the other maybe little like thing to drop in here they're also dog shit for anything but acute pain management, the opioids.
Gianluca Bini: What do you mean?
Annatasha: Thank
Ryan Bailey: chronic opioids get and it causes them to vomit so you have clinic like you have statistically significant changes in pain scores but their lives aren't actually better and they throw up more
Gianluca Bini: Oh, no, no, that's fair. I'm just saying, I'm just saying, you know, the diversion for, from recreational purposes.
Ryan Bailey: oh I just I meant like as using opioids in our patients like short-term short course kind of thing not long-term so like You know, I think, I guess maybe where I'm coming at it from is like, they're kind of dog shit in our patients anyway, in a way.
Gianluca Bini: Like you're saying sending the patient home with opioids is not good.
Ryan Bailey: mean, I had to only choose, I had to only choose one drug to send a painful patient home on, it's not an opioid, that's for sure.
Gianluca Bini: Fair.
Ryan Bailey: was only allowed one.
Annatasha: which one would you pick
Gianluca Bini: Okay.
Gianluca Bini: Fair.
Ryan Bailey: Like when I, when I saw those pain patients, I would tell them opioids are a pulse therapy. We'll do a couple of days. If the dog has a bad day, we can do a couple of days, get them through it. And then we're stopping at cold Turkey.
Gianluca Bini: I think that that's how most people use it though, right? Like, you know, even when you send home a bubonorphine, you don't send them home with a fucking bottle, right?
Ryan Bailey: Oh yeah, for sure.
Gianluca Bini: You can't do like two or three doses.
Ryan Bailey: But like, yeah, yeah.
Gianluca Bini: You know what mean? Like, yeah, yeah, fair, sure.
Ryan Bailey: But those patients like have a chronic condition like osteosaric or osteoarthritis or whatever, you know, they like, I guess that's, that's where I'm coming at it from is like their analgesic efficacy is probably like mild to moderate in the, in the outpatient.
Gianluca Bini: Yeah, it's for a cupid.
Ryan Bailey: And then, and then on top of that in dogs, like what are our options?
Ryan Bailey: Like what, what are you giving a dog for an oral opioid?
Annatasha: tramadol
Ryan Bailey: I always use the paper from Butch Koukanich that was like, showed that they had pretty reasonable plasma concentrations of morphine when administered codeine because of their metabolism. So like, that I think has the strongest evidence, but I don't know if we actually have the efficacy evidence of that drug then being used, unfortunately.
Ryan Bailey: But getting codeine can be a real challenge for sure.
Gianluca Bini: Yeah. Yeah.
Ryan Bailey: It's like schedule two, you got to write a script for it and this and that. It does create a lot of headaches, unfortunately, for prescribers, for sure.
Gianluca Bini: Yeah. Well, yeah, I think we covered most of the
Annatasha: We didn't delve into GABA, but we've talked GABA before, so.
Ryan Bailey: We covered a lot.
Annatasha: What?
Ryan Bailey: That's true. We didn't, we did not get to GABA of last GABA is, I mean, I mentioned it casually that some people love and some people hate it.
Gianluca Bini: Yeah.
Ryan Bailey: You what else we didn't mention? The most important part of this podcast, hot dogs. Anyone had a good hot dog recently?
Gianluca Bini: Well, I was, sat for three hours at fucking Costco, getting zero, but I was, had so many hot dogs around me.
Ryan Bailey: How many, how many hot dogs you put down?
Ryan Bailey: Oh my God. We've been going to Home Depot like every weekend and they got the hot dogs there and I get fix and Frank's fucking like almost every time.
Gianluca Bini: It's usually not the reason.
Ryan Bailey: Karen was like, you know what I can go for? A hot dog. We had hot dogs multiple weekends in a row. I live in the dream right now. me tell you.
Annatasha: Bailey, what is your Lipitor dose? Like, honestly.
Ryan Bailey: And summer is coming up.
Annatasha: dog season.
Ryan Bailey: It's going to be hot dog central.
Annatasha: I honestly think, Bailey, like, I don't know, when you turn 50 or like, I don't know, like an important wedding anniversary, like you should devise like a global hot dog tour where you go on a trip and you just hit the major hot dog spots and then like make it a show or write a book or something like.
Ryan Bailey: can tell you, every time I'm out, I, like, every time I go to a foreign country, I basically try and find a hot dog to eat.
Gianluca Bini: I see your Instagram.
Ryan Bailey: Because, yeah.
Annatasha: We're aware. are aware.
Ryan Bailey: Yeah.
Annatasha: Hmm.
Gianluca Bini: I see your Instagram stories.
Ryan Bailey: Get ready. Get ready.
Gianluca Bini: Oh my God. All right. Well, this was a good chat guys. was cool.
Ryan Bailey: Yeah, I think it was. Hopefully someone can take something away from it other than like, we hate all the oral options we have available to us.
Gianluca Bini: I don't think that that's what we say at all.
Ryan Bailey: Yeah. Yeah.
Annatasha: It's challenging. Don't get me wrong. And it's really challenging too, if there's some sort of clinical preclusion for the NSAID, because that's really like, I think we're the three of us all tend to start.
Ryan Bailey: Yeah, for sure.
Ryan Bailey: Yeah.
Gianluca Bini: That
Ryan Bailey: That's...
Annatasha: But yeah, I mean, it is hard and we didn't get to grab a parent, for example, like we didn't,
Ryan Bailey: Oh, yeah.
Annatasha: We didn't have a chance.
Ryan Bailey: Well, I'm coming up again.
Annatasha: Yeah.
Annatasha: And actually there was something earlier that you said, and I was like, that's my next topic. Like right there is going to be that.
Ryan Bailey: what was it?
Annatasha: I can't tell you. Then it's not a random anesthesia topic.
Ryan Bailey: God damn
Annatasha: Then it's, then it's a premeditated anesthesia topic, which ruins all of our branding guys. Like, yeah. So I can't tell you, but I was
Ryan Bailey: I thought I'd be raining with hot dogs. Am I wrong? Fuck.
Annatasha: The random hot dog podcast. It's basically getting to that at the point.
Gianluca Bini: There you go.
Annatasha: But yeah, no, I can't tell you, but I was totally like, oh yeah, that's what I want to talk about next time.
Ryan Bailey: Fuck.
Gianluca Bini: I got a good topic too. I'm just brewing it. All right. You guys have a good night.
Annatasha: Thanks guys.
Ryan Bailey: Bye.
Gianluca Bini: guys.
